Complaint Information

What is the complaint? (Describe the facts of the complaint situation.)

Who is/are the alleged perpetrator(s)?

How was the patient/resident affected?

When did the complaint situation occur? Was it an isolated event or an ongoing situation? (Include the date, time, time between different events.)

Where did it happen? (In what care unit, patient/resident room.)

How did it happen? What was the sequence of events?

Is a patient/resident or the family of a patient/resident involved?

Who witnessed the complaint situation?

Names of staff or other residents involved. Also, include other persons involved, such as volunteers or visitors.

Was facility made aware of complaint?

What actions were taken by the facility?

To report a complaint regarding a licensed long-term or health care facility or service, contact the appropriate enforcement branch. To determine which enforcement branch to report to, see Contact Information.

Long Term Care Self-Reported Incidents

The Centers for Medicare and Medicaid Services requires long-term care facilities to self-report incidents occurring in their facilities to the Office of Inspector General.